Tooth extraction and consent note template
Write the consent conversation and what you did. The warnings only count if they are the ones you gave this patient.
Template
Tooth Reason for extraction Medical history relevant to extraction Radiograph Consent Options discussed Warnings given Patient decision Procedure Anaesthetic Elevation / sectioning Haemostasis Socket Post-operative instructions Next visit
A filled-in example
Tooth
LR6
Reason for extraction
Gross caries, unrestorable. Patient in pain for three days.
Medical history relevant to extraction
No anticoagulants. No bisphosphonates.
Radiograph
Periapical today. Caries into the pulp. No periapical radiolucency recorded.
Consent
Options discussed: 1. Leave. 2. Extract. Root canal discussed and declined on cost.
Warnings given: Pain, bleeding, swelling, dry socket, infection, damage to the adjacent tooth. Inferior alveolar nerve risk discussed because of the root position.
Patient decision: Extract today.
Procedure
Anaesthetic: Lidocaine infiltration, buccal and IDB.
Elevation / sectioning: Simple elevation. Roots delivered intact.
Haemostasis: Pressure. Socket filled with clot.
Socket: Intact. No retained root seen.
Post-operative instructions
Written sheet given. Advised to avoid rinsing today and to call if bleeding does not stop with pressure.
Next visit
Review only if symptoms worsen. Denture planning at the exam visit.
Let Dentascribe fill this in from your appointment audio.
